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Hold the Smartphone! Tele-epilepsy in a Post–COVID-19 World

      Epilepsy is the third leading contributor to the global burden of disease for neurologic disorders, affecting 65 million people worldwide.
      • Ngugi A.K.
      • Bottomley C.
      • Kleinschmidt I.
      • Sander J.W.
      • Newton C.R.
      Estimation of the burden of active and life-time epilepsy: a meta-analytic approach.
      Besides the direct impact of seizures, people with epilepsy (PWE) face problems including disruption to work and education, psychological stress, and social stigma. PWE also require regular outpatient visits for optimization of antiseizure medication (ASM) therapy, management of epilepsy-related psychological problems, and counseling on family planning. Unfortunately, PWE often have restricted driving privileges that can hinder traveling for these visits. The containment measures established to face the coronavirus disease 2019 (COVID-19) pandemic have further compounded this problem.
      • Fesler J.R.
      • Stanton S.
      • Merner K.
      • et al.
      Bridging the gap in epilepsy care: a single-center experience of 3700 outpatient tele-epilepsy visits.
      Luckily, the rapid emergence of telemedicine, catalyzed by the COVID-19 pandemic, using smartphone applications (apps) offers unique opportunities to address these.
      • Lopez-Jimenez F.
      • Attia Z.
      • Arruda-Olson A.M.
      • et al.
      Artificial intelligence in cardiology: present and future.
      The integration of telemedicine in the health care systems has been accelerated by the increase in smartphone users, with the latest figures estimating more than 3.5 billion users worldwide.
      Statista
      Number of smartphone users worldwide from 2016 to 2021.
      In this issue of Mayo Clinic Proceedings, Tatum and Acton
      • Tatum W.O.
      • Acton E.K.
      Smartphones in epilepsy: the new age of Aquarius.
      discuss the clinical utility of smartphones for PWE in the post–COVID-19 world. The authors highlighted the massive potential of smartphone-based telehealth in epilepsy care, including the diagnostic value of smartphone videos (Figure). The technology can also facilitate remote management of the adverse consequences of recurrent seizures in PWE. Besides, smartphone-based seizure diaries and other apps can help track and document seizure frequency, ASM use, and nondrug therapy administration. Furthermore, smartphone-accessible online communities can be used to improve patient education, to increase health literacy, and to widen support networks for PWE.
      Figure thumbnail gr1
      FigureSmartphone-assisted tele-epilepsy in a post–COVID-19 world.
      An increasing number of patients seeking care and a shortage of neurologists have limited access to neurologic care. This is especially true in epilepsy care, for which a significant shortage of specialists exists. This burden has become even larger with the COVID-19 pandemic because of the self-isolation and strict lockdowns.
      • Fesler J.R.
      • Stanton S.
      • Merner K.
      • et al.
      Bridging the gap in epilepsy care: a single-center experience of 3700 outpatient tele-epilepsy visits.
      Fortunately, access to smartphones and high-speed Internet has now become ubiquitous in both developed and many developing countries.
      • Lopez-Jimenez F.
      • Attia Z.
      • Arruda-Olson A.M.
      • et al.
      Artificial intelligence in cardiology: present and future.
      These advances have made tele-epilepsy a “new normal.” Ample evidence supports the successful use of tele-epilepsy for the diagnosis and follow-up of PWE.
      • Hatcher-Martin J.M.
      • Adams J.L.
      • Anderson E.R.
      • et al.
      Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update.
      A tele-epilepsy initial visit can help diagnose patients living in areas remote from centers with epilepsy expertise. It can also facilitate early identification and referral for an epilepsy surgery evaluation. Follow-up outpatient visits for PWE that focus on seizure control, ASM adherence, ASM adverse effects, and counseling can also be easily performed using this platform. Besides, tele-epilepsy enables direct communication with community providers and allows patients to stay with their local providers while improving consultation and access to higher level epilepsy care when it is needed.
      • Hatcher-Martin J.M.
      • Adams J.L.
      • Anderson E.R.
      • et al.
      Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update.
      Differentiating an epileptic seizure from a psychogenic nonepileptic seizure (PNES) remains a clinical art, one that is supported by video encephalography (EEG). The wide availability of smartphones incorporating a camera makes it possible to obtain a video recording of the ictal event. Examining these videos can help improve the diagnostic accuracy of PNES, especially when motor signs are present. A recent multicenter trial found that a physician review of a high-quality smartphone seizure video resulted in the diagnostic accuracy of epilepsy and PNES >95% of the time.
      • Tatum W.O.
      • Hirsch L.J.
      • Gelfand M.A.
      • et al.
      Assessment of the predictive value of outpatient smartphone videos for diagnosis of epileptic seizures.
      Clinicians also had more confidence in a diagnosis when it included a smartphone video. The ability to identify patients without epilepsy just by reviewing a smartphone video could help realign health care resources to patients for whom the need is highest.
      • Tatum W.O.
      • Hirsch L.J.
      • Gelfand M.A.
      • et al.
      Assessment of the predictive value of outpatient smartphone videos for diagnosis of epileptic seizures.
      During the peak of COVID-19, most medical centers had closed their epilepsy monitoring units either to free beds for patients with COVID-19 or as part of temporarily stopping elective procedures. The diagnosis of PNES by review of smartphone videos certainly can eliminate unnecessary epilepsy monitoring unit admissions in the post–COVID-19 world.
      Current methods for assessing treatment outcomes in epilepsy focus on reducing seizure activity; however, self-reported seizure occurrence can be unreliable. This along with the need to prevent seizure-related injuries has fostered the development of wearable devices, paired with smartphones, to detect seizures in real-time continuously.
      • Bruno E.
      • Viana P.F.
      • Sperling M.R.
      • Richardson M.P.
      Seizure detection at home: do devices on the market match the needs of people living with epilepsy and their caregivers?.
      Seizure detection devices use single modalities or combinations of EEG, video, accelerometry, electromyography, electrocardiography, photoplethysmography, and electrodermal activity.
      • Bruno E.
      • Viana P.F.
      • Sperling M.R.
      • Richardson M.P.
      Seizure detection at home: do devices on the market match the needs of people living with epilepsy and their caregivers?.
      Almost all smartphones have built-in global positioning system receivers, sensing capabilities, and motion detectors or accelerometers, enabling clinicians to “close the loop” by timely detecting seizures. Seizure alarms and safety devices are particularly crucial for those with ASM-resistant epilepsy who are at risk of prolonged convulsive seizures; left unattended, this could lead to sudden unexpected death in epilepsy. Along the same lines, the development of smartphone-compatible electrode caps offers an opportunity for complete EEG systems (“tele-EEG”) that are portable and user-friendly.
      • McKenzie E.D.
      • Lim A.S.
      • Leung E.C.
      • et al.
      Validation of a smartphone-based EEG among people with epilepsy: a prospective study.
      Continuous tele-EEG monitoring could detect spikes that typically precede seizures and alert patients in advance (ie, seizure forecasting). Tele-EEG also has the potential to increase access to EEG services in remote and resource-limited settings.
      • McKenzie E.D.
      • Lim A.S.
      • Leung E.C.
      • et al.
      Validation of a smartphone-based EEG among people with epilepsy: a prospective study.
      Certainly, there is a need for remote monitoring capabilities to manage PWE in the post–COVID-19 world.
      Smartphones also have the potential to change the dynamics of epilepsy self-management. For example, smartphone medication apps can help detect potential medication interactions and remind patients to take their medication on time.
      • Afra P.
      • Bruggers C.S.
      • Sweney M.
      • et al.
      Mobile Software as a medical device (SaMD) for the treatment of epilepsy: development of digital therapeutics comprising behavioral and music-based interventions for neurological disorders.
      The latter increases medication compliance, one of the most significant issues in PWE. On the other hand, seizure diary apps allow patients to record information that may give insight into a patient’s seizure triggers.
      • Afra P.
      • Bruggers C.S.
      • Sweney M.
      • et al.
      Mobile Software as a medical device (SaMD) for the treatment of epilepsy: development of digital therapeutics comprising behavioral and music-based interventions for neurological disorders.
      Information in the form of a medication and seizure diary also makes it possible for neurologists to tailor the treatment plan. Besides, online epilepsy self-management programs such as Internet-based psychosocial interventions can be easily integrated using smartphone apps. Furthermore, smartphone apps, including music and therapeutic video games, present new opportunities to incorporate nonpharmacologic interventions.
      • Afra P.
      • Bruggers C.S.
      • Sweney M.
      • et al.
      Mobile Software as a medical device (SaMD) for the treatment of epilepsy: development of digital therapeutics comprising behavioral and music-based interventions for neurological disorders.
      In addition, smartphone-accessible online communities provide self-learning by providing relevant educational content and expand support networks in the post–COVID-19 world.
      The authors acknowledged that although the possibilities of smartphone-assisted tele-epilepsy care are endless, ethical and legal issues remain a concern. When the pandemic begins to resolve, due diligence is required to ensure that privacy is addressed appropriately. Gaps in Internet and smartphone access, confidentiality, medical errors, and malpractice potential also require attention. Smartphone apps may share sensitive data with advertisers and other third parties in ways not anticipated by users. Besides, devices and sensors designed to detect seizures may collect information on the household’s activities that a patient wishes to keep private. From a diagnostic standpoint, smartphone videos may not capture the entire ictal period or may capture only the postictal period, potentially misguiding the correct diagnosis.
      • Tatum W.O.
      • Hirsch L.J.
      • Gelfand M.A.
      • et al.
      Assessment of the predictive value of outpatient smartphone videos for diagnosis of epileptic seizures.
      Importantly, although the technology is wide-reaching, it cannot replace face-to-face visits (“doctor’s touch”) in some circumstances.
      Smartphone technology, combined with artificial intelligence, is advancing rapidly.
      • Lopez-Jimenez F.
      • Attia Z.
      • Arruda-Olson A.M.
      • et al.
      Artificial intelligence in cardiology: present and future.
      Integrating this technology with tele-epilepsy care will increase health care access for the underserved and rural patients and improves comanagement between local neurologists and epilepsy providers. In the era of increasing medical costs, tele-epilepsy has the potential to reduce health care system costs. Besides, smartphone apps allow continuous monitoring of PWE and use of this information to inform management decisions. Smartphone-assisted seizure detection devices have also opened new avenues to improve both the safety and treatment of PWE. Furthermore, smartphone-assisted tele-EEG will undoubtedly increase access to EEG services to remote and resource-limited populations. Practical tele-epilepsy tools, supported by smartphones, will indeed become the “new normal” for PWE’s long-term management in the post–COVID-19 world. However, the platform requires regulation and standardization to ensure consistency and quality in its application to the care of PWE and to safeguard issues pertaining to privacy and security.

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      Linked Article

      • Smartphones in Epilepsy: The New Age of Aquarius
        Mayo Clinic ProceedingsVol. 96Issue 1
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          Overnight, coronavirus disease 2019 (COVID-19) has forced clinics and hospitals all over the world to transition to mobile health units.1 Now, catapulted into action by a single molecule of ribonucleic acid, the face of health care delivery and the way we practice medicine will be changed forever, making standard operating procedures of clinic-based practice obsolete. Smartphones have become a staple of society and have gradually been incorporated into the infrastructure of many professions, including health care.
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